At HPI, we take our commitment to your health very seriously. That’s why we want to be a key source of tools and information to help you be the healthiest you can be.

Forms for Members

Member Appeal Form

Online Access / PHI Disclosure Form

Member Authorization to Obtain PHI

Member Authorization to Release PHI

Transition of Care Request Form

Download or Order an ID Card

FSA Claim form

HRA Claim form

FSA Transit/Parking form

FSA/HRA Direct Deposit form

Member Reimbursement form (you can also submit your request in My Plan)

Fitness Reimbursement form (you can also submit your request in My Plan)

Weight Loss Reimbursement form (you can also submit your request in My Plan)

Travel Reimbursement form (you can also submit your request in My Plan)

Provider Medical Claim form

Provider Dental Claim form

Short Term Disability form

 



*Claim and reimbursement forms may not be applicable to all plans. Be sure to check your benefit details in your summary plan description prior to submitting a claim or reimbursement form.

Some forms on this page are in PDF format and require Adobe Reader to open.

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Health Plans, Inc. is a Harvard Pilgrim company

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